What are common assessment findings for a patient with pneumonia?
HistoryDuring the intake history, the patient’s potential exposures, aspiration risks, host factors, and symptoms should be reviewed. Show
Potential exposuresA history of various exposures, such as travel, animal, occupational, and environmental exposures, can be helpful in determining possible etiologies and the likelihood of bacterial pneumonia, as follows:
Aspiration risksAs previously discussed, patients at increased risk of aspiration are also at increased risk of developing pneumonia secondarily. Associated factors are as follows:
Additional host factorsAs always, a thorough interview and determination of past medical history is of utmost utility. Inquire about the following:
SymptomsThe clinical presentation of bacterial pneumonia varies. Sudden onset of symptoms and rapid illness progression are associated with bacterial pneumonias. Chest pain, dyspnea, hemoptysis (when clearly delineated from hematemesis), decreased exercise tolerance, and abdominal pain from pleuritis are also highly indicative of a pulmonary process. The presence of cough, particularly cough productive of sputum, is the most consistent presenting symptom. Although not diagnostic of a particular causative agent, the character of the sputum may suggest a particular pathogen, as follows:
Nonspecific symptoms such as fever, rigors or shaking chills, and malaise are common. For unclear reasons, the presence of rigors may suggest pneumococcal pneumonia more often than pneumonia caused by other bacterial pathogens. [34] Other nonspecific symptoms that may be seen with pneumonia include myalgias, headache, abdominal pain, nausea, vomiting, diarrhea, anorexia and weight loss, and altered sensorium. [24] Pertussis is often characterized by its long course of symptomatic cough in adults and by the presence of a whooping sound and/or posttussive vomiting in children. Pneumonia from H influenzae most commonly arises in the winter and early spring. This pneumonia is more often associated with hosts who are debilitated. Patients with Legionella pneumonia often present with mental status changes or diarrhea. Patients may develop hemoptysis or pulmonary cavitations. In addition, unlike other pneumonias, more than 50% of the time Legionella pneumonia has gastrointestinal (GI) symptoms associated with it, such as anorexia, nausea, vomiting, and diarrhea. Hyponatremia is often noted. L pneumophila seems to have 2 forms: Pontiac fever and frank Legionella pneumonia. Pontiac fever has a viruslike presentation, with malaise, fever and/or chills, myalgias, and headache. This form of Legionella pneumonia usually subsides without sequelae. However, frank Legionella pneumonia is very aggressive, with a mortality rate as high as 75% unless treatment begins rapidly. This form typically occurs in individuals who are elderly and debilitated, as well as in smokers and those with COPD, alcoholism, immunocompromise, or have experienced trauma. Physical ExaminationPhysical examination findings may vary, depending on the type of organism, severity of infection, coexisting host factors, and the presence of complications. [24, 35] Signs of bacterial pneumonia may include the following:
Physical findings may include the following:
Examination findings that may indicate a specific etiology for consideration are as follows:
Risk StratificationSeverity-of-illness scores or prognostic models, such as the CURB-65 criteria or the Pneumonia Severity Index (PSI) can be used to help identify patients that may be candidates for outpatient treatment and those that may require admission (see below). The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) proposed guidelines and criteria to determine the severity of community-acquired pneumonia (CAP), which would affect whether inpatient treatment would occur on the ward or require ICU care. [36] Although many of these predictive models were originally designed for assessment of CAP, a retrospective cohort study determined that they may also be applicable to HCAP. [37] CURB-65CURB-65 is a scoring system developed from a multivariate analysis of 1068 patients that identified various factors that appeared to play a role in patient mortality. [38] One point is given for the presence of each of the following:
Current guidelines suggest that patients may be treated in an outpatient setting or may require hospitalization according to their CURB-65 score, as follows:
The percentage of mortality at 30 days associated with the various CURB-65 scores increases with higher scores. The drastic increase in mortality between scores of 2 and 3 highlights the likely requirement for ICU admission in patients with a score of 3 or higher, as shown below:
Pneumonia severity indexThe PSI, also known as the PORT score (for the study by which it was validated), is a prediction rule for mortality based on characteristics derived from cohorts of patients hospitalized with pneumonia. [39] For each of the various characteristics, a predetermined value of points is assigned. In a retrospective cohort comparison of different predictive models applied to HCAP, the PSI had the highest sensitivity in predicting mortality. However, alternative tools, including the IDSA/ATS, SCAP, and SMART-COP (mentioned below), are considered easier to calculate. [37] Demographic factors are scored as follows:
Coexisting illnesses are scored as follows:
Physical examination findings are scored as follows:
Laboratory and radiographic findings are scored as follows:
The combined total points make up the risk score, which stratifies patients into 5 PSI mortality risk classes, as follows:
Current guidelines suggest that patients may be treated in an outpatient setting or may require hospitalization depending on their PSI risk class, as follows:
The Agency for Healthcare Research and Quality (AHRQ) has provided a PSI calculator. [40] It is important to remember that objective criteria and scores should be used as guides only and should always be supplemented with physician determination of the patient's therapeutic needs. The risks and benefits of hospitalization should be weighed carefully, because hospitalization can put patients at additional risk (eg, thromboembolic events, nosocomial superinfection). When a pneumonia is due to mixed etiologies, it is often underestimated by severity scores. [33] IDSA/ATS CAP criteriaPrediction rules like the CURB-65 and PSI have proven useful for standardizing clinical assessments and identifying low-risk patients who may be appropriate candidates for outpatient therapy, but they have been less useful for discriminating between moderate (ward-appropriate) and high-risk (ICU-appropriate) patients. [41] The IDSA/ATS criteria for severe community-acquired pneumonia (CAP) are composed of both major and minor criteria. Although the major criteria indicate clear need for ICU-level care, the minor criteria for defining severe CAP have been validated for the use of differentiating between patients requiring ward-level versus ICU-level care. [41, 36, 42] These criteria are particularly helpful in identifying those patients who are appropriate for admission to the ICU but who do not meet the major criteria of requiring mechanical ventilation or vasopressor support. The presence of three of the following minor criteria indicates severe CAP and suggests the likely need for ICU-level care:
The major criteria are as follows:
Direct admission to an ICU is mandated for any patient with septic shock and a requirement for intravenous vasopressors support or with acute respiratory failure requiring intubation and mechanical ventilation. Biological markersOver the past 10 years, great enthusiasm has been noted regarding the potential of biological markers, such as C-reactive protein (CRP) and procalcitonin (PCT), for the diagnosis and prognostication of pneumonia. PCT appears to be promising, especially as a prognosticator. [43] Other scoring modelsMultiple other scoring models exist that can be used to aid in the prediction of mortality in severe illness (namely in the ICU setting), including the acute physiology and chronic health evaluation (APACHE II) score, [44] simplified acute physiology score (SAPS II), [45] and sepsis-related organ failure assessment (SOFA) score. [46] Whereas most scoring models have been used for predicting outcomes in patients carrying a diagnosis of CAP, the systolic blood pressure, oxygenation, age, respiratory rate (SOAR) model has been validated for predicting 30-day mortality in patients hospitalized with nursing home-acquired pneumonia (NHAP). [47] Still other prediction models regarding pneumonia severity and outcomes are currently being explored and developed, such as the Spanish CURXO-80 tool [48] ; predisposition, insult, response, and organ dysfunction (PIRO) tool [49] ; and systolic blood pressure, multilobar involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation and arterial pH (SMART-COP) tool. [50] ComplicationsPotential complications of bacterial pneumonia include the following:
Parapneumonic pleural effusions and empyemaParapneumonic effusions are common complications of bacterial pneumonia. These pleural effusions occur adjacent to a bacterial pneumonia, resulting from migration of excess interstitial lung fluid across the visceral pleura. Small-volume parapneumonic effusions typically resolve with treatment of the bacterial pneumonia and thus do not require drainage. However, pleural effusions greater than 10mm on lateral decubitus radiographic view should undergo thoracentesis and pleural fluid analysis, Gram stain, and culture to further guide antibiotic selection. Parapneumonic effusions with radiographic evidence of loculated or thickened pleura suggestive of empyema, or pleural fluid pH less than 7.2 or a glucose value less than 60, typically require thoracostomy tube drainage and possible thorascopic debridement via thoracic surgery. Empiric antibiotics for bacterial pneumonias complicated by empyema should include anaerobic coverage, as anaerobic bacteria are often cultured from empyemas. [51] Go to Parapneumonic Pleural Effusions and Empyema Thoracis for complete information on this topic.
Author Justina Gamache, MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center Disclosure: Nothing to disclose. Coauthor(s) Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology Disclosure: Nothing to disclose. Chief Editor Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine Disclosure: Nothing to disclose. Acknowledgements Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association Disclosure: Nothing to disclose. Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Ryland P Byrd Jr, MD Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, East Tennessee State University, James H Quillen College of Medicine; Medical Director of Respiratory Therapy, James H Quillen Veterans Affairs Medical Center Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society Disclosure: Nothing to disclose. Christina Rager, MD Resident Physician, Internal and Emergency Medicine, Olive View-University of California at Los Angeles Medical Center Christina Rager, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and Phi Beta Kappa Disclosure: Nothing to disclose. Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association Disclosure: Nothing to disclose. Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Surgery, Harvard Medical School Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. James M Stephen, MD, FAAEM, FACEP Assistant Professor, Tufts University School of Medicine; Attending Physician, Director of Medical Informatics and Graduate Education, Department of Emergency Medicine, Tufts Medical Center James M Stephen, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment What are the expected findings of pneumonia?Common symptoms of pneumonia include fever, chills, shortness of breath, chest pain with breathing, a rapid heart and breathing rate, nausea, vomiting, diarrhea, and a cough that often produces green or yellow sputum (mucus from the lungs); occasionally, the sputum is rust colored.
What are three 3 physical assessment findings that are noted with the development of pneumonia?Fast, shallow breathing; difficulty breathing; and shortness of breath often are symptoms of pneumonia.
What are the chest assessment findings for a patient with pneumonia?Physical findings may include the following: Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes. Decreased intensity of breath sounds. Egophony.
What focused assessment for pneumonia?A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient's breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope.
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